Saturday, March 31, 2012

It is comprehensive, well researched, and an accurate assessment of Haiti's cholera epidemic. It starts with cholera patient number one in October of 2010 and the article describes the overwhelming challenges to contain cholera now as the rainy season starts in Haiti.

This video regarding cholera was also produced by the Times and Sontag and is excellent.
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MIREBALAIS, Haiti — Jean Salgadeau Pelette, handsome when medicated and groomed, often roamed this central Haitian town in a disheveled state, wild-eyed and naked. He was a familiar figure here, the lanky scion of a prominent family who suffered from a mental illness.

On Oct. 16, 2010, Mr. Pelette, 38, woke at dawn in his solitary room behind a bric-a-brac shop off the town square. As was his habit, he loped down the hill to the Latem River for his bath, passing the beauty shop, the pharmacy and the funeral home where his body would soon be prepared for burial. The river would have been busy that morning, with bathers, laundresses and schoolchildren brushing their teeth. Nobody thought of its flowing waters, downstream from a United Nations peacekeeping base, as toxic.

When Mr. Pelette was found lying by the bank a few hours later, he was so weak from a sudden, violent stomach illness that he had to be carried back to his room. It did not immediately occur to his relatives to rush him to the hospital. “At that time, the word ‘cholera’ didn’t yet exist,” said one of his brothers, Malherbe Pelette. “We didn’t know he was in mortal danger. But by 4 that afternoon, my brother was dead. He was the first victim, or so they say.”

In the 17 months since Mr. Pelette was buried in the trash-strewn graveyard here, cholera has killed more than 7,050 Haitians and sickened more than 531,000, or 5 percent of the population. Lightning fast and virulent, it spread from here through every Haitian state, erupting into the world’s largest cholera epidemic despite a huge international mobilization still dealing with the effects of the Jan. 12, 2010, earthquake.

The world rallied to confront cholera, too, but the mission was muddled by the United Nations’ apparent role in igniting the epidemic and its unwillingness to acknowledge it. Epidemiologic and microbiologic evidence strongly suggests that United Nations peacekeeping troops from Nepal imported cholera to Haiti, contaminated the river tributary next to their base through a faulty sanitation system and caused a second disaster.

“It was like throwing a lighted match into a gasoline-filled room,” said Dr. Paul S. Keim, a microbial geneticist whose laboratory determined that the Haitian and Nepalese cholera strains were virtually identical.

And, as the deaths and continuing caseload indicate, the world’s response to this preventable, treatable scourge has proved inadequate. Cholera, never before recorded in Haiti, stayed one step ahead of the authorities as they shifted gears from the earthquake recovery. While eventually effective in reducing the fatality rate, the response was slow to get fully under way, conservative and insufficiently sustained.

“In the future, historians will look back and say, ‘Wow, that’s unfortunate,’ ” said Dr. Paul Farmer, co-founder of Partners in Health, a nongovernmental organization that provides health care for the poor. “This unfolded right under the noses of all those NGOs. And they will ask, ‘Why didn’t they try harder? Why didn’t they throw the kitchen sink at cholera in Haiti?’ ”

While the world has dedicated $230 million so far to combating the unexpected epidemic, the United Nations is now pleading for an additional $53.9 million just to get the vulnerable displaced population through the rainy months ahead.

At the same time, Haitian cholera victims are seeking compensation from the United Nations, pressing it to accept responsibility. Early on, protests against the United Nations hindered the construction of treatment centers and the delivery of lifesaving supplies. Now distrust of some cholera programs lingers, and the issue has strained the peacekeepers’ relationship with the Haitians they are protecting in an eight-year-old mission to stabilize the politically volatile nation. So, too, have unrelated allegations that they engaged in criminally abusive behavior.

“In telling the truth, the U.N. could have gained the trust of the population and facilitated the fight against cholera,” said Dr. Renaud Piarroux, who led an early investigation into the outbreak. “But that was bungled.”

The United Nations maintains that an independent panel of experts determined the evidence implicating its troops to be inconclusive. Questioned for this article, though, those same experts said that Dr. Keim’s work, conducted after their own, provides “irrefutable molecular evidence” that Haiti’s cholera came from Nepal, in the words of G. Balakrish Nair, an Indian microbiologist.

“When you take the circumstantial evidence in our report and all that has come out since, the story now I think is stronger: the most likely scenario is that the cholera began with someone at the MINUSTAH base,” said another expert, Daniele Lantagne, an American engineer, using the French acronym for the United Nations mission.

Even so, Anthony Banbury, a United Nations assistant secretary general, said last week, “We don’t think the cholera outbreak is attributable to any single factor.”

Many health officials consider the cholera response “pretty remarkable,” as John Vertefeuille, the Centers for Disease Control and Prevention’s director in Haiti, said. A sky-high initial fatality rate of over 9 percent has declined to 1.3 percent (less than 1 percent is considered a well-managed epidemic). And the most recent statistics show new cases dropping to 120 daily.

Others, though, believe the bar for success was set too low and more lives could have been saved. Some critics bemoan weak disease surveillance and case-tracking, others inadequate water distribution and latrine building, and still others what they see as a penny-pinching reluctance to use antibiotics and cholera vaccine.

Also, some think cholera could have been stymied, even eradicated, last winter during the dry season after the first wave. Instead, it flared with the rains even as aid groups shuttered or reduced operations. And now, after another winter without an aggressive prevention and eradication effort, the health authorities fear a reprise.

“I think it’s going to be another bad year for cholera,” said Dr. John Carroll, an Illinois doctor who works in Haiti.

A rapid death

Here in the epicenter of the epidemic, all signage relates to life in the time of cholera. Surrounding the town square are heart-adorned posters that say, “Living with cholera: Always wash your hands with clean water and soap.” Banners slung across the streets, in contrast, bear skulls and crossbones: “Justice and reparations for all victims of the MINUSTAH cholera.”

Inside City Hall, the deputy mayor, crisply dressed in a chambray shirt and slacks, described how he personally buried 27 bodies for fear that workers would not take precautions, how he nearly lost two of his own children to cholera and how he seethed every time Nepalese troops entered his offices.

“They were in my face every day, and the feeling inside me got stronger and stronger,” said Ocxama Moise, the deputy mayor. “A few months ago, I even considered killing a soldier or two to see what would happen. I shared the idea with some friends, and they said, ‘Don’t. You’re an official.’ But it’s only a matter of time before the population finds a way to get justice.”

After the earthquake, when Haitians were living amid cadaver-filled ruins in the sprawling Port-au-Prince area, international health officials were concerned that infectious diseases would rip through the tent camps.

Well before the earthquake, Haiti was fertile ground for a disease that spreads primarily through fecal contamination of water: in 2008, only 12 percent of the population had access to piped, treated water, and only 17 percent to “improved sanitation,” which includes the simplest pit latrines. Haitians’ latrine access actually declined, from 24 percent in 1990.

“For decades we as partners have failed to ensure safe water and sanitation is provided to every resident of Haiti,” said Dr. Jon Kim Andrus, deputy director of the Pan American Health Organization.

But Haiti had escaped the cholera that raged through Latin America in the 1990s, and even the cholera that struck the Caribbean in the 19th century. It appeared “extremely unlikely” that cholera would present itself, a C.D.C. post-earthquake brief said. “The risk of cholera introduction to Haiti is low,” it said, noting relief workers were “likely to have access to adequate hygiene and sanitation facilities within Haiti, such that any cholera organisms they import would be safely contained.”

Seven months later, that assumption would be challenged. On Oct. 8, 2010, hundreds of Nepalese troops began arriving in Haiti after a cholera outbreak in their homeland, where cholera is endemic; the country weathers outbreaks well, with that one causing nine deaths. Cholera also affects individuals differently; many infected develop no symptoms or only mild or moderate diarrhea.

Falling violently ill in October 2010, Mr. Pelette was not one of the lucky ones. Severe cholera causes profuse watery diarrhea, often accompanied by vomiting. Treatment is straightforward: replacing lost fluids and electrolytes, orally or intravenously. But those like Mr. Pelette who get no treatment can become so dehydrated that they go into shock and swiftly die.

Nobody knows for sure, but people here believe that Mr. Pelette was the first Haitian to die of cholera, and, though he was not named, he was presented as the “first case” in The American Journal of Tropical Medicine and Hygiene in January.

Some details in that widely cited article, like Mr. Pelette’s age and date of death, did not match those on his death certificate, obtained by The New York Times. Also, Mr. Pelette does not offer an example of untreated mental illness, as the article contended; he had received care at a hospital for chronic mental diseases, his brother said.

“When he took his pills, he was calm,” Malherbe Pelette said, speaking on the porch of his sundry store. “He would come here every day, stand at the door waiting for a soda or cookies, and give a fist bump to everybody who came in. Sometimes, he showed up completely naked. He had a terrible speech impediment, and when he was agitated, it was really hard to understand him.

“Still, my friend, I cried when he died — a lot, a lot.”

Enter the epidemic

A couple of hours after Mr. Pelette died from what the family priest proclaimed to be a poison of some sort, Rosemond Laurimé, 21, a “small businessman” in his family’s description, got sick in nearby Meille.

In Haiti, small businesses are minuscule, selling mangos or charcoal today to survive tomorrow. Mr. Laurimé peddled soap at a stand outside the Nepalese base, which sits on the banks of a fly-specked stream that flows into the Latem and then into Haiti’s longest river, the Artibonite. Around 6 p.m. on Oct. 16, when he returned to his shack near the base, he was clutching his stomach. Soon, doubled over from violent diarrhea and vomiting, he begged for help.

His grandmother, 70-year-old Marie-Jean Ulysse, did her best, finally summoning a moto-taxi at daybreak to take Mr. Laurimé to the hospital in Mirebalais, run by a Cuban medical brigade. By the time he got there, it was too late: “His body had lost all its water,” Ms. Ulysse said.

On Oct. 17, Mr. Laurimé became the first to die of cholera at a hospital in Haiti. The next day the Cuban doctors, who had seen five dozen cases of acute diarrhea in preceding days, notified the Haitian Health Ministry that something was terribly wrong.

Mr. Laurimé’s grandmother also fell ill and, hovering near death, witnessed the frightening explosion of the epidemic as she lay absorbing fluids intravenously on a hospital cot. She saw a chain of sick prisoners stripped of clothing and handcuffed one to the next. She watched an endless parade of patients carried in, bodies carried out. “I said to my children, ‘Please do your best to take me home because I don’t want to end up in the big hole where they’re dumping all those bodies,’ ” she said.

While she is fine now, Mr. Laurimé’s mother is not. Yverose Fleury wears a cloth binding her midsection in an effort to contain her sorrow. She said neighbors had ripped up her son’s photograph because she keened over it incessantly. “Nothing is the same with us after the cholera,” she said. “My husband is weak and cannot work, my remaining son has a mass on his neck, my little daughter can’t hold down food, and I am sick in the head.”

From Meille, the epidemic coursed through the Artibonite River valley, landing with a thump 46 miles northwest, and downstream, in the coastal St. Marc area. On Oct. 19, three children died in rapid succession in a classroom in the rice fields. On Oct. 20, the St. Nicholas Hospital was overrun. Patients sprawled on every surface, doubled and tripled up on beds, in the halls, in the courtyard and even on the sidewalk outside. By nightfall, there were 404. Forty-four died.

“At that moment, I felt like I didn’t want to live any longer myself,” said Dr. Yfto Mayette, the hospital director. “It was so sudden and so brutal.”

On Oct. 21, as a brass band accompanied Mr. Pelette’s white coffin to the cemetery, the national laboratory completed its analysis of the bacteria. At 11 that night, Dr. Jordan W. Tappero of the C.D.C. got a call in Atlanta from the laboratory’s director: “Jordan,” he said, “It’s positive.”

Louise C. Ivers, Haiti mission chief for Partners in Health, had just arrived in Boston for a meeting. “My first thought was, ‘You can’t be serious.’ Everyone was exhausted.”

In Port-au-Prince, Jocelyne Pierre-Louis, a senior Haitian health official, had steeled herself. “We were in a way waiting for the other shoe to drop,” she said. “We had barely picked ourselves up after the earthquake when the cholera fell on us.” Dr. Pierre-Louis reported to the large tent that replaced her collapsed office after the earthquake.

Dr. Ivers took the next plane back, and Dr. Tappero flew in, too, with the first of 119 C.D.C. employees who would deploy to Haiti. “It was a herculean effort at the time, people working 18, 20 hours a day, trying their best to make a difference,” Dr. Tappero said.

There was much to do, from treating patients to treating water, from importing personnel to training Haitians, from distributing supplies to distributing basic disease and hygiene information. But there were also fundamental decisions to be made, and nobody was firmly in charge. International health officials deferred to the Haitians — “our partners” — but in reality held the purse strings and know-how. This led to an often awkward collaboration, colored by Haitians’ resentment that cholera had been imported in the first place.

It did not help that the initial projection used by international officials for planning purposes — 200,000 cases in six months — was an underestimate. There would be that many cases in three months’ time, with a daily death toll of more than 100 by mid-December.

As the epidemic took off, the players who operated outside the “health cluster,” a consortium of humanitarian groups, were able to react most nimbly.

At first, Doctors Without Borders and the Cuban medical brigades, both self-financed, handled the overwhelming majority of cases. “We felt quite lonely at the beginning,” said Yann Libessart, spokesman for Doctors Without Borders. “It made no sense. Everybody was in Haiti. It was the biggest density of humanitarian actors in the world, and we two organizations were dealing with 80 percent of the cholera.”

Gaëtan Drossart, mission chief for Doctors Without Borders-Belgium, said the health cluster had good intentions, “but there’s a lot of meetings and a lot of blah blah blah.” He said other groups were limited by agreements with donors to working in the earthquake zone and could not redeploy quickly.

Also, everybody initially worried most about the epidemic’s arrival in Port-au-Prince. But Haiti’s meager health care resources have always been concentrated in the capital, and after the earthquake humanitarian personnel and supplies were, too. That would eventually increase the cholera survival odds in Port-au-Prince, which would have a 0.7 percent fatality rate compared with 4.5 percent in the southeast.

But it took several deadly weeks for the disease to forcefully strike the capital, where rehydration solutions were warehoused; water, latrines and medical professionals were more plentiful; and organizations had had time to set up proper treatment centers.

None of this was in place at the start. Doctors Without Borders sent a team to the St. Marc hospital. “It was really, really awful,” Mr. Drossart said. “There were an enormous number of cases, it was totally disorganized, the cholera patients were not isolated, and they were not being treated correctly.”

Even four months later, that hospital did not have cholera cots; patients defecated in bed or risked a potentially fatal drop in blood pressure by getting up, United Nations investigators found. “Hospital staff reported walking on feces in cholera units,” they added.

Understaffed hospitals sometimes discharged patients too soon, sending them home to their deaths. They deputized relatives as caretakers although many patients arrived so dehydrated that they needed intravenous lines and nurses to watch over them. Pregnant women were a particular challenge.

“Our greatest heartbreak is that while the women survived, we only saved one pregnancy,” said Ian Rawson, managing director of Albert Schweitzer Hospital in central Haiti.

Truth vs. ‘The Blame Game’

Within a week of the outbreak, officials in Mirebalais were pointing fingers at the United Nations base, and United Nations officials were trying to stifle what they portrayed as rumors. The struggle began between those who thought that determining the epidemic’s origin was important and those who lamented “the blame game.”

At first, the United Nations said the base’s handling of its waste met international standards — that it used sealed septic tanks, which were regularly emptied by a Haitian contractor, with the waste buried in a proper landfill. But on Oct. 27, Al Jazeera filmed peacekeepers with shovels “working furiously to contain what looks like a sewage spill.” Latrines appeared to be emptying black liquid directly into the river, a reporter said, and the air smelled foul with excrement.

That same day, The Associated Press observed an overflowing septic tank at the base and discovered the landfill to be open pits in a residential area uphill from the community’s bathing stream.

Even four months later, the United Nations’ own experts, examining the base’s supposedly improved sanitation, discovered haphazard piping with “significant potential for cross-contamination” between toilets and showers. They also noted the “potential for feces to enter and flow from the drainage canal running through the camp directly” into the tributary. Contaminants would have been distributed throughout the river delta in two or three days — a timeline consistent with epidemiological evidence tracing the cholera trail, the experts said.

Before long, hundreds of Haitians were marching on the base, with demonstrations spreading to Port-au-Prince and riots developing in Cap Haitien. Edmond Mulet, then head of the United Nations stabilization mission, complained that it was “really unfair to accuse the U.N. for bringing cholera into Haiti.” United Nations officials believed that agitators were taking advantage of the issue to sow unrest before November elections.

But many Haitians were genuinely incensed — and fearful. Some wanted an explanation, others a scapegoat. Voodoo priests were being lynched for their supposed role in bringing the curse of cholera on Haiti, the government said. In early November, the C.D.C. said that Haitian cholera samples matched strains commonly found in South Asia.

Dr. Piarroux, an infectious diseases specialist and parasitologist from Marseilles, arrived to lead a three-week French-Haitian investigation. He and his colleagues built a database of cases, identified geographic clusters and mapped the epidemic’s movement. His conclusion: the only explanation for an outbreak of South Asian-style cholera in a rural area of Haiti home to a Nepalese Army base with a faulty sanitation system had to be infected soldiers on the base itself.

In early December, Dr. Piarroux’s mission report was posted on the Web site of the newspaper Le Monde. Eventually his findings would be peer-reviewed and published in the C.D.C.’s Emerging Infectious Diseases journal. But at that point, he said, he was considered “a renegade and a mythomaniac.”

A leading medical journal, The Lancet, rejected his study after publishing an editorial that said, “Although interest in how the outbreak originated may be a matter of scientific curiosity for the future, apportioning blame for the outbreak now is neither fair to people working to improve a dire situation, nor helpful in combating the disease.” Nonetheless, Ban Ki-moon, the United Nations secretary general, announced an independent panel “to get to the bottom of this and find answers the people of Haiti deserve.”

Money and lives

From the start, financial concerns colored the response to the epidemic, which had killed more than 3,600 Haitians by the first anniversary of the earthquake. It was partly a question of getting money flowing. Some donors hesitated, given the plodding pace of the earthquake reconstruction; others had to wait for a new budgetary year. Some institutions had time-consuming grant or contracting processes.

It was also a question of philosophy. Some health officials wanted to use the least expensive prevention and treatment strategies and to marshal resources for the long battle ahead. Others wanted to employ every available weapon at once, from free drinking water and antibiotics to aggressive case-tracking, mass vaccination, and water and sewer system building. If that meant spending more upfront, so be it, they said.

A year after the earthquake, many organizations were sitting on donations that remained unspent. The American Red Cross, for one, still had nearly half of the $479 million it had raised; it would ultimately dedicate $18 million directly to cholera prevention and treatment. Doctors Without Borders would spend $45 million.

Dr. Farmer of Partners in Health, who calls himself “a maximalist,” said he wanted “health equity” — for the developed world to respond to cholera in Haiti as it would at home. His organization initially requested potable water be trucked into the Haitian heartland so that a traumatized population would not have to filter and treat its water. Purification tablets were delivered instead because it was considered cheaper and simpler, he said.

“There was a fetishization of the simple,” Dr. Farmer said. “But there’s nothing simple about the introduction of a new pathogen or stopping its spread in a water-insecure place. There’s nothing cheap about it, either.”

Dr. Farmer said he kept thinking about the many water stations at the New York City Marathon: “That’s for a sport, for heaven’s sake. You’re telling me the giant humanitarian aid machine can’t do that in an epidemic?”

Mark Henderson, a Unicef official, said water trucking was done inside the town of St. Marc. “I don’t know if it would have been logistically possible to send a water truck to every village in the Artibonite,” he said. “And I’m not sure it would have yielded better results than getting water, which is available locally, and applying chlorine.”

There was also a reluctance to use antibiotics, which can reduce diarrhea, spare suffering and potentially limit the disease’s spread. The Cubans alone, who claimed in a report that without their help “another 1,000 Haitians would have died at Haitian Health Ministry institutions,” dispensed antibiotics to all cholera patients and preventively to their relatives.

World health authorities, concerned with cost and drug resistance, initially said antibiotics should be reserved for severe cases. Nearly three months later, the C.D.C. recommended antibiotics for moderate cases, too.

The fiercest disagreement was over vaccination. Again, citing cost as well as limited supplies and logistical challenges, world health officials initially did not endorse it. Some worried aloud that Haitians could get a false sense of security and become lax about hygiene. Also, one of the two oral vaccines available — Shanchol, the cheaper one — was still under review by the World Health Organization.

But proponents argued that vaccines could save lives and buy time until long-range solutions like water and waste systems were put in place. They called for fast-tracking approval for Shanchol and increasing vaccine production by offering manufacturers purchase commitments. In mid-December, after a C.D.C. analysis indicated that using the available vaccine doses could reduce the caseload by 22,000, the Pan American Health Organization agreed a pilot vaccination project would be useful.

Influenced by arguments against vaccination, though, the Haitian government said no. Choosing a small group to be immunized would inflame tensions, it said; at least 500,000 needed to be vaccinated, said Jean Ronald Cadet, Haiti’s vaccination chief. “They brought us cholera, they have to take responsibility for taking care of it,” he said.

Delay and disbelief

In February 2011, nearly four months after the outbreak, the United Nations’ independent experts arrived in Haiti. The secretary general’s office wanted them to move quickly but not too quickly; it did not want the findings released until the Nepalese contingent had concluded its six-month rotation, Ms. Lantagne said.

When the experts revealed their findings in May, the secretary general’s staff members were surprised, Ms. Lantagne said. Early theories had proposed environmental and climatological explanations for the outbreak. “I believe they fully expected our results to be that there was no possibility cholera was imported into Haiti,” she said.

Instead, the panel said not only that the cholera had come from South Asia but that it originated in the tributary behind the Nepalese base.

Yet the United Nations experts noted that “the introduction of this cholera strain as a result of environmental contamination with feces could not have been the source of such an outbreak without simultaneous water and sanitation and health care system deficiencies.” And they diplomatically concluded that the epidemic was “not the fault of, or deliberate action of, a group or individual.”

The panel had examined the Nepalese base’s infirmary logs and found no reports of severe diarrhea in September or October of 2010. Many took that to mean that the soldiers were probably unwitting, asymptomatic carriers of cholera. But Dr. Piarroux did not think that asymptomatic carriers would have shed enough bacteria to have caused such a sudden, marked contamination of the river. He believed that many soldiers must have had diarrhea — even if it was only mild or moderate diarrhea that, being military men, they did not report to the infirmary.

Testing the soldiers would have been the only way to learn the truth, Dr. Piarroux said. But Haitian health officials were not permitted onto the base to examine the soldiers.

After the United Nations panel dispersed, Danish and American scientists collaborated to scrutinize the Haiti-Nepal connection using the most comprehensive type of bacterial genetic analysis — whole-genome sequence typing.

Dr. Rene S. Hendriksen of Denmark persuaded the Nepalese to provide samples from their outbreak. Dr. Keim’s Translational Genomics Research Institute in Arizona sequenced the DNA, comparing it with Haitian samples already sequenced by the C.D.C.

The Haitian and Nepalese strains were virtually identical — a conclusion the Nepalese were reluctant to accept. “They were trying to fish around for whether our analysis was properly conducted,” Dr. Hendriksen said. “But finally they gave up simply because our data was valid. We agreed we would balance the paper and not get into the blame game.”

Citing this study and other evidence, a legal claim was submitted to the United Nations in November on behalf of Haiti’s cholera victims. Anticipating compensation, thousands flooded treatment centers seeking medical certificates attesting to their cholera. Doctors Without Borders set up a special unit to process the requests, and has asked the United Nations to clarify whether a legal proceeding is even moving forward.

The victims’ lawyers have asked the United Nations to establish a commission to hear the claim. Mr. Banbury of the United Nations said the claim is “under serious review by the legal affairs department.”

“The U.N.’s choice is simple,” the lawyers wrote in a legal article. “It can rise to the occasion and demonstrate that the rule of law protects the rights of poor Haitians against one of the world’s most powerful institutions, or it can shrink from the challenge and demonstrate that once again in Haiti, ‘might makes right.’ ”

A breather, and then disaster

It is tempting now, when reported cholera cases are at a low, for Haitians to relax their guard and for health officials to take a breather. “We are no longer 24/7 cholera,” Dr. Pierre-Louis said.

The same thing happened last year. Then the rains hit, and Port-au-Prince, like other places, experienced more cases — 24,000 — during a 42-day period than at the epidemic’s start. It was a scramble to deal with the surge; many grants had expired, emergency workers had gone home, and treatment centers were closed.

“We had supplies and structures prepositioned, but it wasn’t simple,” said Mr. Drossart of Doctors Without Borders. “We couldn’t keep mobilizing staff for Haiti. There are other things going on in the world.”

Dr. Vertefeuille of the C.D.C. said a key focus now was making the response sustainable without a large international presence. But the government health system, weak and underfinanced, will be hard-pressed to assume greater responsibility.

Dr. Vertefeuille also said cholera was likely to persist in Haiti absent the development of water and sanitation systems, the cost of which has been estimated at $800 million to $1.1 billion.

A singular achievement was the opening of Haiti’s first wastewater treatment site last fall. But humanitarian groups fret that short-term water and sanitation solutions are not being pursued aggressively, and that tent camps have lost the free water and, in some cases, the latrine services that gave them a buffer against cholera.

Many also express keen frustration that the dry season is not being used for aggressive case tracking — chasing the disease into pockets where it flares, investigating and chlorinating the water source, and mobilizing the community. “You can’t wait with your arms crossed until the rain falls again,” Dr. Piarroux said. “You have to go after these areas like firemen trying to extinguish every last burning ember of a forest fire.”

Those who now find the official response sluggish — “daily” epidemic surveillance is posted after a delay of weeks — point to what happened recently in Pestel in southwest Haiti. On Dec. 10, a severely dehydrated man showed up at the cholera treatment unit. The man was too far gone to be resuscitated, said Dr. Seneque Philippe, the physician in charge.

Dr. Philippe’s cholera unit had been inactive because the government had not paid the staff’s salaries. He was not ready for another outbreak. Within two weeks, however, Dr. Philippe believed that he was in the midst of one. People were dying during the long journey down from the rugged mountains to his coastal hospital.

He said that he alerted Health Ministry officials on Dec. 24, and that they were unresponsive. So he contacted an American missionary who had been working in Pestel for decades. She, in turn, tapped into an Internet network of health professionals involved in Haiti and gathered volunteers, supplies and money to pay Dr. Philippe’s nurses.

They arrived Jan. 10 to find the cholera treatment unit overflowing. Most patients were coming from the mountains, so the volunteers, bolstered by other recruits, set up remote treatment tents. They also conducted a door-to-door census in the villages. Including treatment records, too, they calculated 278 suspected cholera cases and 62 deaths in December and January, with most deaths occurring before the ad-hoc group of foreigners arrived.

In Port-au-Prince, Dr. Pierre-Louis of the Health Ministry maintained that the reported outbreak in Pestel had been a “false alarm,” with only 65 cases and three deaths. She said that “the local doctor” had rebutted the larger numbers. But Dr. Philippe, the local doctor, while saying he is “personally aware of only about 15 deaths,” said he knew of 300 cases — a significant outbreak.

“I felt abandoned to handle the problem myself,” he said.

Farther north, one effort to use the dry season to establish a bulwark against the disease was running into other problems. Late last fall, the new government of President Michel Martelly had authorized a vaccination campaign. It was to start small, immunizing 50,000 residents of a Port-au-Prince slum and 50,000 rural residents in the St. Marc area.

The organizers, wishing they could have begun a year earlier and more broadly, were nonetheless relieved to have secured the new administration’s cooperation; it helped that Shanchol, the cheaper vaccine at $1.85 a dose, had been approved.

The organizers — Partners in Health and the Haitian group Gheskio — were also pleased to be starting well before the rains; the vaccine, considered nearly 70 percent effective, is administered in two doses two weeks apart and takes another week to take effect.

In February, Djencia Augustin, 25, a petite, vivacious law student, was racing from mud hut to mud hut in the rice fields of Bocozel to register residents. She wore a T-shirt with a wordy slogan — “We are fighting cholera with Shanchol vaccine without forgetting the other principals of hygiene” — and, in the shade of breadfruit trees, gathered barefoot villagers in threadbare clothing around her as she recorded their information on a computer tablet.

“Some people think cholera is not in our country anymore,” Ms. Augustin told them. “That’s not true. Cholera will come to visit when the rains arrive, so you need to be prepared.” Bocozel seemed eager. Chavan Dorcelus, 58, said: “It’s a real bonus for us. Plus it’s free, and it can’t hurt.”

Told that pregnant women were ineligible, Fada Joseph, 24, patted her belly. “That’s not really fair. I’m very scared of cholera,” she said. “And if I got an abortion, would that help?”

But in mid-March, radio reports characterized the project as an experiment on Haitian guinea pigs. With $370,000 of vaccine sitting in coolers, a government bioethics committee took up the issue. The campaign appeared in peril. Dr. Farmer said last Thursday, however, that the Haitian health minister had just promised him that she would resolve the issue in the coming week.

‘Would have burned it down’

In Meille, the walled gate at the United Nations base is freshly painted now with the insignia of Uruguayan peacekeepers. The Nepalese are gone.

The mission itself is reducing its forces nationwide. Nepal’s troop strength is being cut by two-thirds, more than any other country’s. United Nations officials said that this was unrelated to tensions over cholera. But people here think otherwise: “If they hadn’t left, we would have burned it down,” Deputy Mayor Moise said of the base.

In February, an Uruguayan advance guard was there, removing latrines and generally “sanitizing the operation so previous problems do not repeat themselves,” as one soldier said.

Across the street, the open pits where the base’s waste used to be deposited were fenced. “They stopped dumping the foreigners’ poo there after the cholera,” said Ludner Jean-Louis, a farmer, his two cows tied to trees.

Mr. Jean-Louis, who had survived the disease himself, added, “I don’t guess you can be mad at MINUSTAH for the cholera. Only for the poo.”

Behind the base, the stream where the epidemic began bustles with life now as it did before the outbreak; many who live and work beside it have no other access to free water.

Recently, just behind the base’s barbed-wire periphery, Dieula Sénéchal squatted with her skirt hiked up, scrubbing exuberantly colored clothes while a naked 6-year-old girl, Magalie Louis, defecated by the bank, gnawed on a stalk of sugarcane and then splashed into the water to brush her teeth.

Approaching with a machete on his way to hack some cane, her gap-toothed father, Légénord Louis, said Magalie had contracted cholera late last year but after four days of “special IVs” was restored to health. He knew the river water was probably not safe, he said, but, while they brushed their teeth in it, they did not swallow.

For drinking water, Mr. Louis said, his family relies on a local well. But he lives from hand to mouth and cannot afford water purification tablets; the free supply he got in 2010 ran out long ago. So he gambles. “If you make it to the hospital,” he said, “you survive the cholera.”

Friday, March 30, 2012

Aftershocks

A Report from Haiti

Created 03/27/2012 - 10:45am

Fran Quigley

On a sweltering afternoon in Port-au-Prince, I walked with a group of visiting U.S. human-rights lawyers up to a dusty lot filled with shacks, tents, and broken-down buses and cars. These are the makeshift shelters of families who lost their homes in the earthquake that devastated Haiti on January 12, 2010. One family was using a dirty blanket as one wall of its shack. Others had covered the gaps in their ceilings with gray plastic sheets branded “USAID.” One of the residents of the camp gestured toward a hillside packed with more tents and shelters. “From January 2010 until now, nothing has been done,” he told us.

We walked past temporary toilets. A resident said they’d been “full” for several months. In fact, excrement had piled up high above the rim of the pits. As we moved between shelters, we found a woman squatting between two tents to relieve herself. We saw another woman who had an open wound the size of a baseball on her left foot; she was trying in vain to keep flies from landing on its crimson surface. Insects swarmed over the mix of gray water and raw sewage running through shallow ditches in the narrow passageways between tents.

The residents of this camp are not the only Haitians still suffering the effects of the earthquake. Throughout Port-au-Prince, chalky white chunks of concrete remain piled up where buildings once stood. Nearly every inch of available space in the city is covered with improvised havens of plastic tarp and scraps of wood, serving as uncertain shelter for more than half a million people whose homes were destroyed in the quake. In shelters built on rock and dirt hillsides, residents try to sleep standing up while rainwater and mud pour over the ground beneath them.

Even so, many of these people consider themselves lucky compared to the tens of thousands who were crushed under buildings that collapsed in the quake, including schools, hospitals, and government offices. At many sites throughout the city, it took weeks to finish pulling bodies out from under the tons of broken concrete. Once the bodies were retrieved, workers would pile them next to the street, douse them with gasoline, and set them on fire.

Mario Joseph, a Haitian human-rights lawyer and the director of Bureau des Avocats Internationaux (BAI), insists that the real tragedy in Haiti was not caused by an act of God: “We had an earthquake, yes, but far too many people died in this earthquake. And that is because we in Haiti have no respect for the rule of law.” Most of those who died in the quake were crushed to death by the collapse of poorly constructed houses perched on steep, over-crowded hillsides. Haitian building and zoning codes prohibited such houses, but the laws were never enforced. Now, rebuilding is stalled because investors are reluctant to finance construction in a country where it can be very difficult to prove legal title to land. Haiti’s constitution guarantees the right to decent housing, food, and health care, but these are promises the government has long been unable to keep. One predictable result of the government’s failure to restore basic social services has been the rapid spread of cholera, which has claimed seven thousand lives since an outbreak began in October 2010. The death toll would have been much lower if the government had been functioning properly but, as Joseph says, “we have this problem of impunity.”

Jean-Claude “Baby Doc” Duvalier began his rule over Haiti in 1971, after the death of his father, François “Papa Doc” Duvalier. In 1986, Duvalier fled the country, bringing to an end a two-generation reign of repression and plunder. In January 2011, Jean-Claude Duvalier suddenly returned to Haiti, reportedly in an effort to access millions of dollars in a frozen Swiss bank account. He hoped for the backing of new president Michel Martelly, who has close ties to Duvalier supporters. So far, Duvalier’s calculations appear to be on the mark. A Haitian judge has ruled that Duvalier cannot be prosecuted for human-rights crimes. Although that decision is being appealed, the onetime “president for life” has remained free to move around Port-au-Prince, where he is often seen in high-end restaurants and nightclubs. Martelly has said he thinks Duvalier should be granted amnesty.

“Can you imagine any other country where a former dictator accused of political murders and leaving people to rot and die in prison is allowed to just walk back into his country and remain free?” asks Reed Brody of Human Rights Watch. “But I think people are just shrugging their shoulders, and saying, ‘Well, that is Haiti.’ In so many ways, Haiti is the floor, the bottom, of what we expect internationally, both economically and in the performance of its government and justice system.”

Haiti’s long history of dictatorships and, more recently, a series of coups d’etat have produced a revolving door of judges and prosecutors with reputations for corruption. A Creole proverb says,Konstitisyon se papye, bayonet se fe—“the constitution is paper, the bayonet is steel.”

Joseph and the BAI are filing civil suits on behalf of some of the victims of the Duvalier-era human-rights abuses, and they have compiled extensive evidence of the financial crimes committed by Duvalier, his family, and his aides. Joseph’s organization and its U.S.-based sister group, the Institute for Justice and Democracy in Haiti (IJDH), are leading the appeal of a decision blocking a Duvalier trial on charges of political violence, and they have helped persuade the Inter-American Commission on Human Rights and the United Nations to issue strong calls for a Duvalier prosecution. This is not the first time Joseph and his colleagues have helped prosecute political crimes in Haiti. They obtained convictions and multi-billion-dollar judgments against Haitian generals and paramilitary personnel after a 1994 massacre of civilians in the coastal community of Raboteau. That success is now cited as a template for bringing Duvalier to justice.

“A Duvalier process and trial would mean so much for Haiti,” says Joseph, who grew up in the extremely poor Artibonite Valley area of rural Haiti. “It will help people believe in the system of justice if they see a defendant held accountable who stole our country’s money and killed and imprisoned people. Not only will it let the people know we are a democracy that will seek justice. It will send a signal to current and future leaders that, if they commit crimes, they too will be prosecuted.”

The reconstruction efforts in Haiti are usually represented by images of engineers digging wells, construction workers building houses, and doctors treating the sick. But the physician most associated with relief efforts in Haiti, the Harvard Medical School professor Paul Farmer, places much of his hope for Haiti in the hands of lawyers. “The current justice system’s shortcomings—especially its unavailability to the poor—underlie almost all of Haiti’s problems, including political instability, poverty, violence and corruption,” says Farmer, who helped found IJDH and serves on its board of directors. “BAI and IJDH raise people’s expectations of their leaders and create a viable peaceful avenue for combating the great injustices in Haitian society.”

But Haiti is still a place where a lawyer cannot simply file a lawsuit and expect an impartial judge to rule promptly and dispassionately on the merits of the case. Even judges able to resist the temptation of bolstering their meager salaries through bribes are usually reluctant to rule against the powerful in a country with a long history of political violence.

So Joseph and his colleagues have turned to grassroots advocacy, helping organize demonstrations by the Raboteau victims, as well as a network of families of political prisoners who protested mass arrests after the 2004 coup d’etat. They now encourage and advise camp dwellers, grassroots women’s groups, and even a progressive newspaper, which is housed in BAI’s headquarters. BAI lawyers provide feedback when camp dwellers draft public statements. They also provide legal assistance when camp dwellers get in trouble with the authorities for conducting public demonstrations—such as a recent sit-in that stopped traffic in downtown Port-au-Prince. The lawyers confront judges and prosecutors only when they have community members at their side. “The poor too often have little or no education, so they have problems getting their voices heard,” Joseph says. “Our job is to help their message reach the ears of those who have wealth and power.”

That message must also resonate outside Haiti, given continued international involvement in Haiti’s economy and politics. That’s why attorney Brian Concannon, Joseph’s former colleague at BAI, helped found the Boston-based IJDH after he moved back to the United States in 2004. Together, the Haitian and U.S. attorneys have filed international reports and complaints on behalf of Haitian political prisoners, winning the only such case ever decided by the Inter-American Court of Human Rights. Concannon and IJDH help international journalists and lawmakers understand the election abuses that are a routine feature of Haitian politics. (Last year, Martelly won the presidency only after the majority party was barred from the elections.) And the Haitian-U.S. human-rights team has shown a willingness to take on the most powerful global players. In November, after several studies showed that the cholera outbreak was triggered by shoddy sanitation practices at a UN peacekeeper base, BAI and IJDH filed a multi-billion-dollar claim against the United Nations on behalf of five thousand Haitian cholera victims.

Later on the day of our visit to the Port-au-Prince camp, we returned to the BAI headquarters. It was growing dark under the unlit rear shelter where a press conference had been held earlier in the day. Now, volunteer law students sponsored by various human-rights organizations gathered in a circle of folding chairs along with Joseph, the U.S. visitors, and finissants—recent Haitian law-school graduates serving an apprenticeship at BAI.

Joseph invited the young Haitian lawyers to introduce themselves to the visitors. In soft-spoken Creole, they shared stories of personal struggle that mirrored the recent history of their country. A young man named Michel was illegally arrested and held in prison for nine days without charges. A woman named Natasha witnessed both her father and brother being shot in the aftermath of the 2004 coup. Her family could not find a lawyer to pursue justice against the killers. Now, Natasha lives in a displaced-persons camp, where she met a BAI attorney who helped her begin a career advocating for housing rights.

Joseph listens to the finissants’ stories, and reminds the group that these young Haitian lawyers represent more than his country’s reputation for poverty and lawlessness. They also represent the possibility that Haiti will finally reclaim its proud, two-hundred-year-old legacy of liberation. “Haiti is the mother of liberty,” Joseph says. “I hope we are now building a new generation of Haitians committed to human rights.” That commitment will obviously require political activism, but it will also require basic legal reforms. “Since the rule of law in Haiti has been almost nonexistent,” Joseph says, “you have to build it.”

I know of at least three Cholera Treatment Units or Centers where I have worked since November 2010 that are no longer set up to accept cholera patients. And these three places did great work for thousands of very sick cholera patients.

So where will patients from these areas go now when cholera strikes again?

Friday, March 16, 2012

"I am an invisible man. No, I am not a spook like those who haunted Edgar Allan Poe. Nor am I one of your Hollywood-movie ectoplasms. I am a man of substance, of flesh and bone, fiber and liquids--and I might even be said to possess a mind. I am invisible, understand, simply because people refuse to see me."

Manushka is a 24 year old young lady who I met in Soleil near the pediatric clinic. She told me about her life in Soleil and losing her father to cholera.

She seemed like one of thousands of people in Haiti's slum... filled with talent that willl never be brought to the surface or be used for productive purposes. With only four years of education, Manushka just seems so smart.

I spoke with a friend of mine who is CEO of a company in Port-au-Prince. We talked about Manushka. He asked me if Manushka could fill out an application form for possible employment in his company. I told him that I didn’t know.

So I related this conversation to Manushka and she cringed when I told her that she would need to fill out an application form if she wanted this job. She said she would give it a try.

So my driver and I dropped her off at the company the other day and Manushka did her best to fill out the application form. Even though she checked that she was an "homme", she got the job.

Her first day was Monday of this week.This seems like good news. Manushka will have a reason to get up in the morning and make herself look presentable. She will have to be disciplined to arrive at work sharply at 7 AM each morning. And if she does these things and performs at work, she will have a constant income for the first time in her life.

And Manushka will be able to support her eight siblings in Soleil better than she can now.

I have learned that good intentions don't always lead to good results. I hope Manushka's new job doesn't back fire on her.

In her part of Soleil it will be well known that she has a job. I hope that she is not robbed. I hope she is not bribed for money. I hope her two hours of electricity per day is not disconnected. I hope her new job won't hurt her in any way.

And I have a bigger question.What would happen if, instead of a 99% unemployment rate in Soleil (my figure), there was a 50% unemployment rate? What if every other Manushka in Soleil had a full time job that did not involve selling charcoal, mangoes, or carrots on the street corner?

What would that do for all of Soleil’s woes? Would Soleil's water be cleaner? Would infant mortality in the slum decrease?During the last 10 years when we have asked people in Soleil what they want the most, they have uniformly replied "jobs". They didn't ask for more guns or bullets or violence or kidnappings, or MINUSTAH, or sick babies, or illiteracy. They asked for jobs.

Tuesday, March 06, 2012

The following post is a description of two interviews I had today with young ladies that live in Cite Soleil in Port-au-Prince. My main questions for them revolved around cholera.

But first of all, I want to give a very brief summary of where I think the public water comes from in Soleil. These few sentences will be boring, but they are important. Water engineers and smart people out there, please help me if this is incorrect in any way, and I will correct my mistakes. More than ever in Soleil, access to good water can mean the difference between life and death.

The water that is pumped to Soleil is from a water reservoir in LaPlaine which comes from the water table (anba woch) and this water is pumped underground by pipes to the large imposing water tower sitting at the entrance to Soleil off of Route National 1.

Two white PVC pipes run along the northern side of the water tower. One carries water up and the other carries water down to pipes below the ground and through these pipes water is pumped to “basins” spread all over Soleil. A ‘basin” is a series of pipes and spigots that people have access to in the slum. People come to these basins and fill up white buckets of water, put them on their head, and walk back to their shack. It is up to them to treat their own water with Clorox or aquatabs because it is my understanding that the water from LaPlaine has not been treated.

Another important supply of water to Soleil are water trucks that transport water in to the slum. I don’t know enough to say much about this water’s origin, its purity, or its potability. But these points would not be hard to answer.

The importance of this "chain of flow" of water is to figure out the best places to test and treat the water for cholera.

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This is Saturday, February 25, 2012, and there is no pediatric clinic today in Soleil. So my goal was to go the Boston neighborhood in Soleil to check out information regarding cholera. I wanted to find out if the people in Boston have any means to fight the oncoming fourth wave of cholera when the rainy season starts again very soon in April.

I met Natalie the secretary who works in the pediatric clinic in the back of Soleil where I work during the week. Natalie is a great gal and lives in Soleil at Soleil 19, just several blocks from the clinic. She and I were going to walk the mile through the slum to Boston but she had some news for me.

Natalie calmly informed me that there was “a war” going on in the streets between the gangs of Boston and Beleko. These are two large neighborhoods that abut each other in the northwest part of the slum. Natalie said that one of the gang leaders in Beleko was shot and killed two days ago and things were still dangerous in the streets.

She advised me to stay in the back part of Soleil where we were and I could talk to her neighbors about cholera. That seemed like fine advice to me.

So we walked through the little pathways of Soleil to Natalie’s mother’s one room shack and sat down inside the room. It was very clean and not too hot.

Natalie said in a hushed voice that we were sitting right next door to the Soleil gang chief’s shack. I asked her about him and she said he was benevolent to the people around this neighborhood and she referred to him as "Patwon". She also said the people in Soleil are not as mean as the warring people in Boston and Beleko.

I told her I wanted the Soleil people’s perspective on cholera. I asked Natalie to talk to some people close by that had suffered from cholera or had family members suffer from cholera. She concurred and said “no problem”. Natalie said it would not be hard to find people very familiar with cholera.

She stepped outside of her mother’s place and called out the name “Venise”. A few seconds later a young lady walked in carrying her three-month old baby and sat down in a white plastic lawn chair in front of me.

Venise--Photo by John Carroll, February 25, 2012

Venise did not know her own age but she states that when she was 19 years old her mother threw her out of the house in Jeremie and somehow she ended up in Soleil. (Jeremie is a city about 10 hours by public transportation from Port-au-Prince.) She does not know how many years she has been in Soleil. She does not have an electoral card or an identity card, and her birth certificate is lost somewhere in Jeremie. Venise appeared to be about thirty years old.

Venise told me that she had never been to school and does not know how to read and write. She has no job and depends on her neighborhood (lakou) in Soleil to support her. Her neighbors give her and her children some food when they have extra. Typical food for Venise and her children are rice, pureed beans, ground corn, and some meat sauce. If the neighbors have no extra food that day, Venise and her children don’t eat.

She lives in a one room shack near Natalie’s mother and her neighbors pay her 550 Haitian dollars (about 70 dollars US) rent each six months to her landlord.

Venise has five children ages 14, 8, 4, 2 and the happy three-month old she was holding. The two oldest children are from one man and the three youngest from second man. She reports the same as most Haitian women in this social strata about her childrens’ fathers: “Yo pa occupe nou...” which means that the men do nothing for her or her kids.

Venise, with the help of her lakou, had her two oldest children in schools in Soleil. But their father took them with him moved them into a tent city in Fort National. However, the father’s girlfriend was beating the two kids so severely that a neighbor in another tent took them in and is letting them sleep and eat whatever she can find for them. Neither of the two kids are in school now.

Venise no longer sees the older kids in Fort National and she has the three youngest children with her in Soleil.

Venise told me that one day in November, 2011 when she was 9 months pregnant with the baby she is holding today, she abruptly started having diarrhea and began to vomit. And so did her eight year old daughter Mimi who still lived with her. They both went to St. Catherine’s Hospital Cholera Treatment Center (CTC), which is just a couple of blocks away, and was run by Doctors Without Borders-Belgium.

Venise said she went into shock quickly and required 23 liters of IV fluid over several days. Mimi required only a couple of IV liters to feel better. They both survived because the CTC was so close and they went quickly. And the CTC was well stocked with supplies and had people who knew what they were doing. Venise delivered the three-month old baby girl a couple of weeks later.

Doctor Without Borders-Belgium left St. Catherine’s in December and the hospital is now run by MSPP (Public Health Department of Haiti). When Doctors Without Borders was in charge of St. Catherine’s, there was no charge. But now it costs five Haitian dollars (about 75 cents) for a dossier to be made and for a consult with a doctor. If one is admitted to the hospital, MSPP charges one hundred Haitian dollars (12 US dollars) for the use of the bed no matter how long the patient’s stay is in the hospital.

I asked Venise where she gets her water now. She gets her water from some public pipes here in the neighborhood (basin) which comes from the big water tower that sits in the entry way to Cite Soleil. One bucket of water costs one gourde (a few pennies).

She said that she did not treat her water with Clorox or Aquatabs before she got cholera and she doesn’t treat the water now either because she has no money. So she and her kids are drinking this water which is not really clean.

I asked Venise if she is afraid of cholera. She said she is afraid and that “it is coming back.” When I asked her how she knows cholera is coming back, she said “everyone says it is”.

I asked Venise if she was happy with her life in Soleil. She said “Yes, because I have no other place to go.”

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Manushka

The second person I talked to was a polite young lady named Manushka. She said she is 24 years old.

Manushka was born and raised in Soleil and lives in the same neighborhood near Soleil 19 near Natalie and Venise. She has no children but she is the oldest of seven and she feels responsible for her six younger brothers and sisters.

Manushka told me that her mother died in 2000 and stated that her mom “was sick all the time”. Her father buried her mother in Drouillard Cemetery in the slum. This funeral and burial cost her father quite a bit so Manushka could not continue in school and she never went back to school. She has four years of education and can write her name and do simple math.

She told me that 13 months ago her father died from cholera. When I asked her what year that would have been, she did not know.

Manushka said that her father did manual labor on Kafou Aeropo (Airport Corner) and drank water while he was at work. He became sick on a Monday and was taken directly to Doctors Without Borders-Tabarre and died on Wednesday. They did not allow visitors in the cholera tent and so she was unable to see her father until after he died. He is buried in the Drouillard Cemetery too.

Manushka seems very bright.

I asked her if she knows why Haiti has cholera. She said no and then turned the question around on me and asked me if I knew why.

I told her that it was inadvertently introduced here by the MINUSTAH soldiers in central Haiti in 2010.

She just slightly smiled and said nothing.

I asked her if she ever heard this explanation and she said no. I asked her if MINUSTAH was doing a good job in Soleil and she said no. She said they are not doing much good work and that they abuse people by hitting innocent people in Soleil. I asked her if MINUSTAH still shoots in Soleil, and Manushka said no.

When I asked her if the Haitian National Police (HNP) abuse people she said yes. She said they tear up ID cards and hit people in Soleil. However, she said that the HNP needs to be supported over MINUSTAH because the “Haitian police are us...they are from here.”

I asked Manushka if she went to church. She said no. When I asked her what religion she is, she said that she has no religion. I asked her if she was mambo (worship the devil) and she still replied no. She said that she doesn’t believe in God...that she is an atheist.

I asked Manushka if she was happy with her life here in Soleil. She said no because of all the “gang fighting and people running”.

When I asked Manushka where she gets her water, she said it is from the same pipes (basin) where Vanesse gets her water. But Manushka treats her water with Clorox.

When I asked her what Soleil needs, she replied clean water, clean streets, and education for young people. She said that she would like to go to a professional school (I think she meant vocational) and that if she learned something and got a job that would be good for her and good for Haiti too. She would like to become a cosmetologist.

I asked Manushka if she became sick where she would go for medical care. She stated that she has nowhere to go since MSPP took over St. Catherines and charge 25 gourdes for a dossier. And she said that she has no money for any medication that would be prescribed anyway.

When I asked Manushka if the Haitian government was going to do anything to help Soleil, she said no. She said that the Haitian government doesn’t respect the young people of Soleil or think that they have any importance, so they are ignored.

She said the only help Soleil gets is from foreigners coming with trucks of water and Clorox. She viewed this as the only good thing being done for the people of Soleil.

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After talking with these two young ladies, Natalie and I left her mother’s room and walked back through Soleil towards the pediatric clinic. I stopped at a basin where women and children were collecting water coming from the pipes. I asked the women if they put Clorox in the water and they said yes and they asked me to buy them more Clorox.

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So here are my questions and comments about the water and cholera in Soleil:

Could the water be tested coming from LaPlaine to see if it is cholera free? Can it be tested as it comes out of the spigots at the local basins in Soleil just before it flows into the white buckets?

Can there be a constant supply of Clorox and aquatabs for the hundreds of thousands of people who live here?

Can thousands of liters of Ringer’s Lactate (and IV tubing and setups) be brought to St. Catherine’s NOW so it is ready in one month for the wave of cholera that is to hit.

Can nurses be hired by MSPP for St. Catherine’s CTC NOW so they are ready to begin work. And can cholera community health educators start circulating through Soleil NOW educating people about what is most likely coming back in a few weeks.

Doctors Without Borders and other NGO’s did all they could and saved many lives in Soleil with their CTC. But they are gone from Soleil now and St. Catherine’s Hospital and the CTC are definitely not ready right now for a big hit of cholera patients.

It is time for other agencies to kick in. The Haitian Prime Minister just resigned the other day and there is much political fighting high up in the Haitian government. This instability could easily disrupt the flow of cholera materials that is needed to save lives in Soleil.

The two girls I interviewed are typical of the people of Soleil. They help each other as much as possible under almost impossible circumstances. They want to live as much as we do. We have 16 months of experience with cholera now in Haiti and need to learn from our mistakes. Stopping cholera deaths in Soleil is completely possible. We just have to have the will.

Early today in pediatric clinic in Cite Soleil I had a young mother bring in her 10 month old baby boy. She told me that he started having diarrhea yesterday. He had ten white watery stools yesterday and five similar stools this morning. He is drinking some and nursing some but clinically appeared lethargic and moderately dehydrated.

It was an easy diagnosis. I thought this baby boy had cholera.

Most of my pediatric patients in the clinic actually do have diarrhea. But this baby's diarrhea was different and his clinical presentation was consistent with cholera.

So what should I do?

The population of Soleil is estimated to be in the hundreds of thousands. But no one knows for sure. And before cholera struck Haiti in 2010, Soleil had the usual horrible diseases of poverty. Now it has had cholera added to its "differential diagnosis" . And the experts from around the world say that cholera will return here in a few weeks when the rainy season starts.

Is this baby the harbinger of the next wave of cholera?

Working in Cite Soleil as a physician is challenging. We all know that the people from the slum are suffering and dying from stupid deaths everyday. This is no secret. And intervening to help them is not always straight forward.

Soleil should not have a monopoly on medical helplessness and hopelessness, but it sure seems to.

I first worked at St. Catherine’s Hospital in Soleil in 1987. I had the opportunity to work with Dr. Paul Blough, a retired OB-GYN doctor from Peoria, Illinois. Dr. Paul delivered over 10,000 babies at St. Catherine’s in the 1980's and 90's. He was in his 70’s and 80’s when he worked in Soleil and he gave excellent obstetric care. And so did the Haitian midwives that worked with him.

The Daughters of Charity, who are an order of St. Vincent de Paul Sisters in Soleil, worked at St. Catherine's during those years too. The hospital functioned and many patients were treated every day.

Doctors Without Borders, which responds to "hot zones" around the world, has been running the hospital since shortly after the 2010 Haitian earthquake. But they left the hospital three months ago because their contract with the Haitian government expired.

Doctors Without Borders had an army of medical people including public health experts that tracked cholera in the Soleil slum neighborhood-by-neighborhood and street-by-street. Cholera tents were erected at St. Catherine's Cholera Treatment Center (CTC). These tents were away from the other post earthquake tents that housed general medical patients. Thousands of cholera patients were treated and many lives were saved.

And inside the hospital that was not damaged by the earthquake, Doctors Without Borders offered a small emergency room, surgery department, internal medicine and pediatric wards, and an obstetric unit. Many patients from Soleil were operated because the surgeons, anethesiologists, and surgical nurses were on site.

Entrance to St. Catherine's Hospital Cite Soleil

But all has changed. St. Catherine's is no longer bustling with activity like it should be in this huge destitute slum.

Ministre de la Sante Publique et de la Population (MSPP), which is the Haitian Ministry of Health, is in charge of St. Catherine's Hospital now. MSPP has government hospitals in each of Haiti's ten departments. However, they don't function well.

St. Catherine’s is in terrible condition now. It is staffed by a tiny handful of excellent Haitian doctors employed by MSPP, but the hospital has very few medical supplies.

And there is a new problem.

Patients are now charged five Haitian dollars (75 cents US) to have a check up. And if they need to be admitted to St. Catherine's they are charged two hundred Haitian dollars (25 dollars US) for a bed. Doctors Without Borders did not charge.

Patient's families have to provide the sheets for the bed and food for the patient. And family members bathe the patient and empty the bedpan.

Medical supplies and medication are provided by the hospital if they have them. But if they are not available, the patient's family has to try and buy them somewhere on the street which is frequently impossible to accomplish. (How would you buy 4-0 chromic sutures?)

So lack of money stops people from coming to St. Catherine's in Soleil in the first place.

The hospital has very few patients right now. With Soleil's population, there should be patients everywhere. The three stretcher Emergency Room is usually empty of patients and staff. It has one tall narrow cabinet with some medications to treat infectious diseases and hypertensive emergencies.

The General surgery ward at St. Catherine's is competely closed as are the operating rooms. There are no surgeons or anethesiologists.

The Obstetric ward is open and seemed to have the most patients of any inpatient unit. And C-sections can be done under a spinal...but only when a nurse anethetist and an obstetrician is present.

The Internal Medicine ward has a smattering of a few ill elderly people. There is no oxygen to give patients in respiratory distress and very few medications. It is very depressing to see the elderly lying about sick and in disarray.

The Pediatric ward has a few patients but they should have many more. There are many sick kids in Soleil. St. Catherine's has three Haitian pediatricians employed by MSPP that run an outpatient clinic at St. Catherine's for a few hours Monday-Friday. And these same three physicians admit the sick babies who they think they can manage in the hospital with its meager supplies and technology.

Pediatric Ward, St. Catherine's Hospital (Photo by John Carroll)

So what does all this mean?

It means that St. Catherine's Hospital, run by MSPP, is offering very inferior care to hundreds of thousands of people from Soleil who become sick or who are injured.

How does this scenario play out on a day by day basis?Let me give a couple of examples.

A few days ago while rounding in St. Catherine’s Internal Medicine ward, I spotted a sweet appearing old lady lying in a corner bed. Her name is Famia and she is 72 years old. She had three interested family members seated near her by her bed. Famia was alert and had a very kind appearing grandmother type of face.

I asked her what was wrong. She said that she had been given a shot in her left buttock five days prior and develped a problem.Famia rolled over and showed me her massively swollen and tender left gluteal area. Her buttock and thigh were red and warm to touch all the way to her mid thigh. There were ominious appearing purple patches of skin over the buttock.She obviously had a very infected buttock and and thigh and needed surgical debridement and antibiotics to have a chance at survival.

Famia's Infected Thigh (Photo by John Carroll)

However, Famia was receiving no IV, no antibiotics or pain meds, and there was no operating room or surgeon waiting to help her. Her leg was septic and she would be too if nothing was done very soon.

I told her that I would pray for her and slowly backed away from her bed not knowing what to do here in Soleil with more neglected slum pathology. Famia had impending death written on her forehead.

I walked to the pediatric ward with Famia on my mind. Prayer is most important, but is that all I could do. What about "works"? There had to be more that we could do here and right now.

And then it dawned on me...why not transfer her? I have a good friend who is a surgeon in private practice in Port-au-Prince, and her number was on my cell phone.So I called her immediately and she was accepted over the phone right away. I rushed back to her bed, gave her family members the address to the private hospital and surgeon and some money for public transportation and they said they would take her.

Famia made it there and is being treated...I don’t know if she will survive, but her chances at survival in Soleil were zero. And none of this was necessary if St. Catherine's was functioning at a basic level like it should be. ( While posting this, I just received an e mail from the private hospital director stating that one of his surgeons is taking care of Famia and she is doing well.)

And on a bigger picture, what will the people of Soleil do when the rainy season starts and cholera starts infecting them again?

St. Catherine's is going to triage people with cholera AWAY from St. Catherine’s to CTC’s because they have no intention of treating cholera like Doctors Without Borders did during the last two years. Patients will be sent to the small CHAPI health center near the entrance of Soleil or to some other CTC somewhere in PAP run by NGO's. (Hopefully, Samaritan's Purse will reopen their 200 bed CTC in Soleil if necessary.)

And what about my baby in the clinic with cholera yesterday? The baby was still alert enough to take fluids by mouth, but with the weekend approaching, I told the mother that she needed to take her baby to a CTC in the neighborhood of Delmas so the baby could have an IV.

Mother listened but she politely refused.

She knew St. Catherine's is right across the street and could not understand why she could not take her baby there. And she said she would get lost in the Delmas neighborhood and would not be able to find the CTC.

So I reluctantly gave here some packets of oral rehydration salt and some money for transportation to Delmas if she changed her mind.

It would be easy to blame this mother. But we can't especially under the inhumane living conditions in Soleil. There is no structure here except hob-nob attempts at daily survival.

And guess what? Many more mothers in Soleil think the same way that this mother thinks. They have no money for transportation out of the slum and they have more kids at home to worry about. So they have to do their own triage and decide which of their kids go to school, which kids eat, and which ones get medical care. They have to pick which children will live and die.

I recently talked to an official for MSPP in downtown PAP. I specifically asked the official why things are so atrocious in MSPP run hospitals. The official said that there is not enough funds dedicated to MSPP for anywhere in Haiti, let alone Cite Soleil. The official said there is not the “governmental will” to allow MSPP hospitals to function at a higher level.

This leads us back to money again. Where is all the post earthquake billions of dollars of pledged money for Haiti?

I can sure tell you where it isn't. It is not at St. Catherine's Hospital in Cite Soleil.